Tendons connect muscles to bones and span across joints, enabling those joints to be moved. One of the most important tendons in the lower leg is the tibialis posterior tendon. The muscle is deep in the calf, and becomes a tendon before passing immediately behind the bone on the inside of the ankle and attaching to bones in the instep, most particularly the navicula.

The tibialis posterior tendon helps support the arch of the foot and provides stability when pushing through the toe-off part of the walking cycle. If this tendon becomes inflamed, degenerated or torn, it can become “dysfunctional” leading to pain on the inner aspect of the ankle and a gradual loss of arch height (flatfoot deformity).

Signs and symptoms of tibialis posterior tendon dysfunction:

  • Pain and swelling on the inside of the ankle
  • Loss of the arch and the development of a flatfoot
  • Pain on the outer side of the hindfoot, due to bone impingement
  • Weakness and an inability to stand on the toes
  • Hindfoot stiffness and limping

Risk factors

Tibialis posterior tendon dysfunction can occur in people of any age, but is most common in women over 50 years of age. Risk factors include:

  • Obesity
  • Diabetes
  • Long-standing or lifelong “physiological” flatfootedness
  • Previous surgery or trauma, such as an ankle fracture on the inner side of the foot
  • Local steroid injections
  • Inflammatory diseases such as rheumatoid arthritis


The diagnosis is based on both a history and a physical examination. You may be asked to stand and walk to view how your foot functions. As the condition progresses, the heel tilts outward and the forefoot rotates in the same direction. There is local tenderness and swelling, weakness of hindfoot rotation and loss of joint movement. Standing X-rays, and an MRI of the foot may be required.


Without treatment and over time, the flatfoot that develops from tibialis posterior tendon dysfunction eventually becomes rigid. Arthritis develops in the hindfoot. Pain increases and spreads to the outer side of the hindfoot. There is usually a limp and wearing shoes may be difficult.

The treatment will depend on how far the condition has progressed, age, general health and activity level. In the early stages, tibialis posterior tendon dysfunction can be treated with physiotherapy, non-steroidal anti-inflammatory medication, and splintage of the foot for 6 weeks in a CAM-boot to rest the foot. Shoe inserts (insoles) should incorporate a heel wedge and arch support. If the condition is advanced, a custom-made ankle-foot orthosis may be helpful. If non-operative treatment doesn’t work ( and this is often the case), an operation may be needed. Several procedures can be used to treat tibialis posterior tendon dysfunction. Often, more than one procedure is performed at the same time. Treatment will be individualised.

Surgical options include:

  • Tenosynovectomy: In this procedure, any inflamed tissue surrounding the tendon is cleaned away.
  • Tendon Debridement and Repair: Degenerative tendon tissue is removed and any tendon defect or tear repaired.
  • Lengthening of the achilles tendon.
  • Osteotomy: This procedure changes the alignment of the heel bone (calcaneus).
  • Tendon transfer: This procedure uses an adjacent healthy tendon to help strengthen the damaged tibialis posterior tendon.
  • Lateral column lengthening: In this procedure, a bone graft is used to help re-align the foot.
  • Spring ligament repair: This ligament is an important supportive structure of the arch of the foot and is often also torn.
  • Arthrodesis: This procedure fuses two or more bones together, realigning the hindfoot, eliminating pain and preventing recurrent deformity, whilst permitting excellent function.

  All surgical procedures involve risks. The information provided here is for general educational purposes only. For specific advice regarding tibias posterior tendon dysfunction, please book an appointment with Dr Newman.

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